Tight Glycemic Control

What is it? How to reach it?

T2DM

As-Salamu ala man it-taba al-huda

I would like to welcome you to today workshop on insulin treatment of T2DM

Dont think about our world, but Feeling in our heart that we wish a knowledge

Oh my Lord advanced me in knowledge and give me understanding

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Type 2 Diabetes Mellitus (T2DM)

is a heterogeneous disorder may have comorbid illness treatment must be individualized the common mistake in management is early diagnosis or to neglect treatment completely FBG >126 mg/dL and PPG >200 mg/dL are risk for diabetic complications
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Optimal Treatment for T2DM

Normalizes blood glucose levels: (A1C <7.0%) by increasing insulin sensitivity
Lifestyle

interventions of diet Exercises: brisk walking for 20 minutes

Normalizes blood pressure: <130/80 mmHg Normalizes the lipid profile: LDLcholesterol <100 mg/dL

Treatment for T2DM

Education OHA Insulin Others

Clinical Exercises Nutrition

As Salaamu ala Manittaba al Huda
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T2DM: Unmet Needs

Long-term glycemic control
Reduce macro- and microvascular complications Improve quality of life

Earlier diagnosis
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Long-term Glycemic Control

Proportion of patients attaining treatment goal [UKPDS 49]

HbA1C <7%
Group Diet Insulin SUs Metformin*
*obese patients
Turner R, et al. JAMA 1999; 281: 2005-12
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3 years 25% 47% 50% 44%

6 years 12% 37% 34% 34%

9 years 9% 28% 24% 13%

Relation of A1C levels and Risk of Complications in Diabetes Mellitus

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Diabetes complications Per 10,000 patient/year

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1032 745

100
80 60 40 20 0 5 6 7 8 487 359

655

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11
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Mean A1C levels during treatment

UKPDS 35. BMJ 2000; 321: 405-12

Therapeutic Option
Dont be sad: al Baqarah (2): 112
Believe in and surrender to Allah with all his heart Doing the right things right Reward with his Lord, no fear, no regret (no depression, no anxiety)

The art of medicine: IQ ~ EQ ~ SQ Depends on the condition of patients, individually

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Management (1)
Education

life-style changes

About DM Risk of complications Principles of Therapy Oneself Skills

Tim Edukator
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Non-pharmacological
Medical nutrition therapy
Small

frequent portion of diet Eat if hungry and stop before sat Need dietician help

Regular exercises
Part

of life part of treatment Tahajjud may help the musholli (patient)

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Medical Nutrition
Dietary modification is an important component of a weight loss program (level 1) Programs produce about 7% loss decrease in body weight significant changes in FBS (~200 mg/dL at baseline to 150 mg/dL) after 3-6 months of weight loss (level 1) The best predictor of the glycemic response to weight loss is initial FBS (level 3)
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Medical Nutrition

Nutritional alias Dietary planning Adjusted to body need All allowed, but kendalikan nafsu QS an-Nisa 79 Reach or maintain ideal body weight High CH, Low fat MetS
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Medical Nutrition Caloric intake Patients age Sex Height Weight Activity Nutritional content Timing of meal
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Medical Nutrition
Weight loss of 5-10% of body weight
improve glycemic control long-term, but it may require weight losses of twenty percents of body weight to normalize glucose levels (level 2)

Dietary modification is an
important component of a weight loss program (level 1)

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Exercises
Should aimed at an increase general physical activity Improvement and/or normalization of CV risk factors: hyperinsulinemia; decreased HDL-cholesterol and hypercholesterolemia Decrease or inhibit the atherosclerosis process Should be weighed against cardiovascular event: ACS, arrhythmias and cardiac arrest Jalan kaki lebih baik dari naik delman
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Exercises
Exercises alone

vs. no exercises small effects on glycemic control and weight loss (level 1) Diet + Exercises produces better maintenance of weight loss, but do not show significant differences in glycemic control (level 2)
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Pharmacological Treatment
Initial treatment for T2DM is OHA Increasing duration of T2DM, multiple OHAs in combination are usually required UKPDS demonstrated a progressive loss of insulin-secretory capacity as diabetes progressed many T2DM need insulin
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Dont be sad
OHA Sulfonylurea Biguanide Alpha-glucosidase Inhibitor Insulin sensitizer Insulin

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Oral Hypoglycemic Agents

Sulfonylurea (SU)

Decrease A1C by 1-2% (level 1A) Weight gain ~2-3 kg (level 1A) Tight glycemic control by SU does not cause increase risk of mortality, myocardial infarction, or other cardiovascular events (level 1A)
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OHA

Biguanide (Metformin)

Decrease A1C by 1-2% (level 1A) Less weight gain and less hypoglycemia vs. SU/Insulin (level 1A) Tight glycemic control using metformin is associated with reduced all-cause mortality, any diabetes-related endpoints, and stroke (level 1A)
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OHA

Acarbose
Decrease A1C by 0.7 to 1.8% (level 1A) In combination 0.2 to 1.4%, without significant changes in body weight or hypoglycemia (level 1A) Poor compliant due to flatulence and diarrhea (level 1A)

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OHA Thiazolidinediones

Pioglitazone and Rosiglitazone Monotherapy decreases A1C ~ 0.9 to 1.5% (level 1A) In combination with metformin reduces A1C ~1.0 to 1.2% (level 1A); increases body weight, dose dependent, by ~0.7 to 1.9 kg, not associated with hypoglycemia (level 1A)
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OHA

Meglitinide Analogues
Repaglinide and Nateglinide May reduce A1C ~1.0 to 2.0% (level 1A) Risk of hypoglycemia similar with SU use (level 1A)

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OHA

Alternatives

Selected Minerals, Vitamins, Fiber, and Herbs Antioxidants: vitamin C, vitamin E, Coenzyme Q, biotin Rationale? The impact on glucose control? Doses? Side effects?
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The Cure
When I am sick, then He restores me to health [al Quran s. 26: 80]

Medical Reflexology Meditation Reiki

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Grading of T2DM Based on Level of Fasting Glycemia & Suggestion of Insulin Treatment FBG (mg/dl)
< 140 140 - 200

Grade
Mild Moderate

Insulin Therapy & Dose required

Virtually never needed Basal insulin is needed : Intermediate acting insulin at bed time or Long-acting insulin 1 2X/day Doses required : 0.3 0.4 /kg/day Intermediate-acting 2X/day + short-acting insulin Doses required : 0.5 1.5 /kg/day

> 200

Severe

>250

Very severe Treated as Type 1 diabetes (initially) 1 2X basal + 3X bolus (pre-meal)

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Concern About Possible Adverse Effects of Hyperinsulinemia

Relationship of hyperglycemia and macrovascular disease in T2DM is difficult to demonstrate Insulin resistance and/or hyperinsulinemia associated with T2DM, hypertension, and dyslipidemia
CVD: a direct complication of DM
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Early Insulinization
... Do well to other people as Allah has done well to you, and do not spread corruption in the world. Surely Allah does not like corrupters
[al Qur'an s. al-Qoshosh (28): 77]

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Early Insulinization
When FBS >160 mg/dL or A1C >8.4% contributes more to hyperglycemic exposure FBS ~ poorly regulated hepatic production subacute glucotoxicity Basic concept of basal insulin: reduce FBS; using a bedtime injection of NPH or glargine OHA may enhance endogenous prandial insulin production
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Early Insulinization
The issues: dose amounts and timing of insulin delivery
Risk of hypoglycemia (high dose) Hyperglycemia (not enough)

Need a basal insulin level to overcome hepatic glucose production Need a rapid insulin to overcome increase after meal glucose levels (prandial hyperglycemia
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Single Shot
480 400 320

Intermediate insulin Plasma glucose

240
160

80 07.00
12.00 18.00 24.00

07.00
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Twice Daily Shots

480 400 320

Intermediate insulin Plasma glucose

240
160

80 07.00
12.00 18.00 24.00

07.00
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Multiple Shots
480 400 320

Regular insulin Plasma glucose

240
160

80 07.00
12.00 18.00 24.00

07.00
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Summary
Diabetes is a chronic metabolic disease Risk of complications Risk of b-cell pancreas loss overtime At time T2DM need exogenous insulin, but risk of hypoglycemia and hyperglycemia Mixed fast acting and long-acting insulin is needed the art of medicine The art of medicine can be learned
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Matur Agenging Panuwun

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